Patient Feedback Form Oak Brook IL

How did you hear about us? 
Ad   Friend  Family  Referred by my dentist 
Other - - Please Specify:  

Did you find our working hours convenient for you?
Very convenient   Convenient  Somewhat convenient   Not convenient 

Was your phone contact with our office informative and courteous?
Excellent   Very Good  Good  Average  Poor

Upon entering our office, were you properly greeted, and acknowledged by our staff?
Excellent   Very Good  Good  Average  Poor

Did the waiting area look clean and orderly?
Excellent   Very Good  Good  Average  Poor

How long did you wait before being seen by the doctor?
0 minutes  5 minutes  15 minutes  30 minutes   More

Was the receptionist helpful, polite and pleasant?
Excellent   Very Good  Good  Average  Poor

Was the dental assistant(s) friendly, supportive and confident?
Excellent   Very Good  Good  Average  Poor

Was the Dentist who attended you confident and focused?
Excellent   Very Good  Good  Average  Poor

Did the Dentist explain your treatment, answer your questions, and listen to your concerns?
Excellent   Very Good  Good  Average  Poor

Did the clinic operatory seem clean and hygienic?
Excellent   Very Good  Good  Average  Poor

The level of dental treatment I received was:
Excellent   Very Good  Good  Average  Poor

How would you rate the overall quality of service you received at our office?
Excellent   Very Good  Good  Average  Poor

Would you recommend us to your family, friends and co-workers?
Yes   Maybe  No 

Did you find our Website was a helpful resource?
Yes   Needs Improvement  No 

Additional Comments or Suggestions:

If this is a complaint, do you wish to be contacted for follow-up?
Yes   No

The following information is optional, but is required if you wish to be contacted:

Full Name:

Email Address:

Telephone: